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Inspection Summary

Overall summary & rating


Updated 15 February 2019

We rated the service as good because:

  • Feedback from clients and carers was very positive. Staff supported clients in a very caring way to participate in activities run by the service and in the community.
  • Staff responded to changing risks to clients, or posed by them.
  • The service provided a robust prescribing and therapeutic programme tailored to the needs of clients and in line with National Institute for Health and Care Excellence guidelines.
  • The service used newly appointed staff to specifically reduce the number of clients not attending appointments by identifying those at risk of disengaging from or experiencing unplanned exit from the service during treatment. They contacted those at risk between appointments and co-ordinated their care and treatment between teams with CGL Manchester.


  • There was a breach of infection control with wet mops and cloths not stored correctly to the extent that they were being stored over unopened boxes of needles for the needle exchange. The boxes were wet.

  • In one location a security door was damaged allowing the public uncontrolled entry.
  • The provider should review its current infection control training to understand whether it is adequate for the needs of the service
  • Clients’ care records were not always updated in a consistent format. Individual care and recovery plans were not updated as individua plans. Instead staff updated the ‘contacts’ section with all new information. New users of the system would be unclear were to access current information or assessments.
  • Management systems were not always effective. Despite monthly clinical audits being completed the issue of safe storage of cleaning equipment and needles for the needle exchange was not identified. There was a failure to maintain the buildings environments to a safe standard.
Inspection areas


Requires improvement

Updated 15 February 2019

We rated safe as requires improvement because:

  • The provider did not always provide care and treatment in a safe way. At Bradnor Point, we found cleaning materials and medical equipment stored together in the same cupboard, creating a risk of contamination.

  • At 43a Carnarvon Street, the security door at the bottom of the stairs to the first floor was insecure, allowing visitors unauthorised access to upstairs toilets and a group work room.


  • Clients’ records contained risk assessments and staff were aware of risk and knew how to update the providers risk register and escalate risk issues.

  • Key workers told us and records confirmed that staff recognised and responded to warning signs and deterioration in client’s physical and mental health.

  • Staff had a good understanding of and responded appropriately to safeguarding concerns.



Updated 15 February 2019

We rated effective as good because:

  • Clients had comprehensive care and recovery assessments in place. These covered their physical health, their substance misuse and included links between mental and physical health issues.

  • Staff provided evidence based treatment interventions.

  • Former clients were used as a resource by the provider to support clients as recovery champions and volunteers.


  • Staff recorded all new assessments and information within the ‘contacts’ area used in the client computer system rather than updating the assessments made when clients entered the service. Staff demonstrated that they knew where to access this information and we observed them deal with outside enquiries quickly and comprehensively using the ‘contacts’ area as the reference point. However, new staff would expect to find new assessments updated as specific plans other than within the generic ‘contacts’ log.

  • The provider should review its current infection control training to understand whether it is adequate for the needs of the service.



Updated 15 February 2019

We rated caring as good because:

  • Staff treated clients with compassion and kindness. They respected clients’ privacy and dignity, and supported their individual needs. Staff involved patients and those close to them in decisions about their care and treatment. The provider included clients when they made changes to the service.

  • Staff communicated well with clients so they understood their care and treatment. This included finding effective ways to communicate with clients with communication difficulties.



Updated 15 February 2019

We rated responsive as good because:

  • Clients could access the service closest to their home when they needed it. Waiting times from referral to treatment and arrangements to assess, treat and discharge patients were in line with good practice.

  • There were newly appointed staff whose role it was to identify clients at risk of disengaging from the provider. They contacted these clients outside the service and between appointments to reduce the incidents of nonattendance at appointments.

  • The provider encouraged clients to access community services such as Alcoholics Anonymous and Narcotics Anonymous, education and work opportunities.

  • The provider aimed to meet the needs of all clients using it – for example, by facilitating a Lesbian Gay Bisexual Transgender foundation group and a Farsi-speaking Narcotics Anonymous group.



Updated 15 February 2019

We rated well led as good because:

  • Managers and leaders had the skills, knowledge and experience to perform their roles.

  • Staff had the opportunity to discuss strategies, systems and processes with leaders in a candid way.

  • The management of risk, issues and staff performance was effective.

  • Engagement between staff, clients, carers, managers and senior leaders was central to the way the provider operated with evidence that all groups were consulted and the way the provider delivered its service.


  • The provider should review its management procedures to ensure senior managers are aware of all environmental issues and action is taken to resolve them.

Checks on specific services

Substance misuse services


Updated 15 February 2019